Research Objectives: The purpose of our proposed longitudinal mixed-methods study is to build on our initial work by analyzing relationships over time (2008-2014), which will allow us to understand the effects of PCC on quality and quality on costs and develop a better understanding about variations in PCC/quality and characteristics distinguishing CLCs with higher levels of PCC implementation. Our specific objectives are to: 1) examine whether the level of implementing PCC is associated with higher quality (fewer adverse events) over time as measured by a set of 28 MDS QIs; 2) examine whether higher facility-level quality is associated with lower patient-level costs; and 3) identify key structural and organizational characteristics, and PCC implementation and quality processes that distinguish CLCs providing high PCC and quality from other CLCs where PCC and quality performance is lower (mixed or low) in both domains by conducting site visits at selected facilities. Project Background/Rationale: PCC implementation underway in VA, combined with the use in VA of both the Artifacts Tool and MDS-based QIs, represents a unique research opportunity (supported by VA operations) to assess the impact of implementing PCC on quality in a large, integrated delivery system with a sizable number of sites. Using cross-sectional data, we have found that there is a statistically significant relationship between the extent of PCC and an MDS- based composite measure of quality; and, there is preliminary evidence that higher levels of quality are associated with lower costs. This study will allow us to 1) identify the extent to which PCC implementation leads to lower adverse event rates; 2) identify the extent to which quality leads to costs; and 3) understand what distinguishes the high from the low performing CLCs. Dr. Christa Hojlo has emphasized that PCC implementation, quality, and costs are all important areas for researchers to study in order to build an evidence-base in the VA for CLC quality improvement and inform and shape practice. Project Methods: In Objective 1, we will 1) measure PCC implementation by assessing Artifacts Tool scoring methods and evaluating alternative summary scores and latent scores; 2) measure quality by creating a composite score using facility-level data on 28 MDS QIs data; 3) evaluate the relationship between the MDS-based quality composite score and Artifact Tool PCC scores using a Bayesian model; and 4) evaluate the relationship between the individual MDS-based quality indicators and Artifact Tool PCC scores using a Bayesian model. In Objective 2, we will examine if higher quality is associated with lower patient-level costs through both individual and time-series regressions as well as through Bayesian modeling. Finally in Objective 3, we will conduct twelve site visits in order to understand variations in key health systems factors (structural characteristics, PCC/quality processes, and organizational infrastructure) for CLCs in high performance versus low and mixed performance categories. Sites will be selected according to their performance status (PCC implementation and Quality).